Patient nameDate of BirthStreet AddressPhone NumberSection 1 :Family HistoryMother : ( name ) , ( age ) , (illness)(name : ..........) , ( age : .......... ) , (illness : ...........)Father : ( name ) , ( age ) , (illness)(name : ..........) , ( age : .......... ) , (illness : ...........)Brothers : ( name ) , ( age ) , (illness)(name : ..........) , ( age : .......... ) , (illness : ...........)Sisters : ( name ) , ( age ) , (illness)(name : ..........) , ( age : .......... ) , (illness : ...........)Others Relationships : ( name ) , ( age ) , (illness)(name : ..........) , ( age : .......... ) , (illness : ...........)Section 2 :Social HistoryDoes anyone in current family smoke cigarettes ?yesnoHas anyone in child's biological or natural family (parents, siblings, or grandparents) had:Bleeding DisorderTuberculosisAsthma/Allergy (particular to medicines)Kidney StonesHeart Attack or Heart DiseaseSeizures or EpilepsyDiabetesCancerAnyone in family die before age 40?check if yesDoes anyone other than parent take care of the child regularly?yesnoWho ?Does child attend school (or daycare) regularly?yesnoName of schoolGradeRegular ClassSpecial ClassGrade FailuresyesnoWhich grade(s):Home situation: Who shares your home with you and the patient?Is this child adopted?yesnoSECTION 3:PAST MEDICAL HISTORYDuring pregnancy with this patient, did patient's mother experience:Toxemia or Pre-eclampsia,Vaginal BleedingAlcohol IntakeSmokingTake any prescriptionsTake any drugsMarijuana useFever(Check if Yes)What type of delivery?vaginalC-sectionWhat birthweight?Did delivery occur: at/before 37 weeks (If Yes, do you know why?Were there any complications at birth?yesnoWas the baby yellow in color? (Yellow-Jaundice)yesnoHow many days old was the baby when he/she went home?Were there any difficulties after birth?yesnoDid the baby need oxygen?yesnoWas the baby blue in color?yesnoHas the child ever been hospitalized overnight or had any operations? If yes, please list each admission:yesnoplease list each admission:Hospital, Dates, ReasonDid Patient have ?AsthmaHay FeverFood AllergyPenicillin Allergy.(Check if Yes)Has patient ever had:Hepatitis (Yellow Jaundice)MeaslesChicken PoxEar InfectionsVDBee Sting AllergyAny Other AllergyScarlet FeverGerman Measles Mumps Strep Throat(Check if Yes)List any other serious illness or injuries that the patient has had:List all medications which this child uses regularly or has used regularly in the past:Send Message
